Gastrointestinal
Haemorrhage
Mrs Esther Mitchell
Clinical Teaching Fellow
Acute Block Objectives

GI Bleeds
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Assess the likely causes of upper GI bleeds from
history and examination
Initiate management of acute upper GI bleeds
Distinguish common causes of lower GI bleeds
from history and examination
Initiate appropriate investigations for lower GI
bleeds
Assessment of the Acutely ill patient
Resuscitation
Today’s Objectives

Knowledge
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Know what colours are likely to represent blood in a vomit or
stool sample
Understand why blood changes colour in the GI tract
List common causes of lower GI bleeds
Know symptom complexes that clinically differentiate these
causes
Know the initial management of upper GI bleed patients
List features on history and examination that suggest Varaceel
bleeds
List 5 other causes of upper GI bleed
Describe the distinguishing features of these other presentations
Today’s Objectives continued

Knowledge continued
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
Skills
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Understand resuscitation of bleeding patient, including use of
fluids and blood
Think about different types of investigations and what information
can be obtained from them
Fill in an upper GI bleed care pathway
Be able to calculate a Rockal score
Prescribe blood and IV drugs correctly
Attitudes

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Appreciate knowing purpose of investigations allows correct
choice of investigation
Be aware of how serious upper GI bleeds can be
Give GI bleed patients appropriate priority
Outline

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Patient Pathways
General principles & Worked Examples

Recognising a GI Bleed
Causes of GI Bleeds
Management
Investigations

Including Case Study Group work sessions
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Patient Pathway – “Normal”
Presentation
History & Examination
Provisional Diagnosis
Investigations
Specific Diagnosis
Treatment
Patient Pathway – “Acute”
Presentation
Unstable Patient
Haemostasis
Medical
Management
History &
Examination
Resuscitation
Investigations
Stable Patient
Further Investigations
Confirm Diagnosis
Specific Treatment
Working
Diagnosis
Recognise a GI Bleed
What’s blood?



What colours can blood be?
Why does it change colour in the GI tract?
Do you always see blood if there’s GI
bleeding?
Colours of Blood
Colour
Vomit
Stool
Bright Red
√
√
Dark Red
x
√
Green
x
x
Black
x
√
Brown
√
x?
No motion / vomit
?
?
Why does blood change
colour?

Stomach – Acid

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Small Bowel – Digestive enzymes
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
Bright Red -> brown / coffee grounds
Bright Red -> Dark Red
Colon – Bacteria

Bright Red-> Dark Red -> Black
PR Bleeds (haematochezia)
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Black – Cecum or Upper GI
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Dark Red – Transverse colon, Cecum
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Melaena, Tar like, smelly
Or Upper GI, large volume
Loose / soft stools
mixed with stools
Bright Red – Anus, Rectum, Sigmoid


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Mixed with stools - sigmoid / descending
Coating stools / on paper – rectal / anal
Rarely massive upper GI bleed
Consider occult GI blood loss
when:

Unexplained anaemia

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Sudden episode of hypotension and
tachycardia, easily corrected

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Low volume chronic bleeds, eg Gastric Ca,
Cecal Ca
Acute upper GI bleed
melaena follows hours later
History of bleeds / risk factors, shocked pt

Symptoms missed, or appear later
Causes of GI Bleed

Brainstorm all causes of GI bleeds
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
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Groups, 2-4 people
2 minutes
Make 2 lists, most common to least common

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Divide into upper & lower GI causes
1minute
Causes - Upper GI (80%)
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Peptic ulcer disease – 50%
Erosive Gastritis / Oesophagitis – 18%
Varices – 10%
Mallory Weiss tear – 10%
Cancer – Oesophageal or Gastric – 6%
Other, including Dieulafoy’s lesion – 6%
Causes - Lower GI (20%)
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Diverticular disease - 60%
Colitis (IBD & ischaemic) – 13%
Benign anorectal (haemorrhoids, fissures,
fistulas) – 11%
Malignancy – 9%
Coagulopathy – 4%
Angiodysplasia – 3%
Post surgical / polypectomy
Management

Urgency of Management

Resuscitation including Transfusion
Medical Management
Haemostasis
Treatment of underlying disease

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Urgency of Management

Severe bleeds
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Moderate bleeds
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Resuscitation
IP investigation +/- treatment
IP observation till bleed stops
Often OP investigation +/- treatment
Mild / low risk bleeds
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Early discharge
OP investigation +/- treatment
Severe Bleeds

Severe / significant bleed if any of the
following:

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
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Tachycardia >100
Systolic BP <100 (prior to fluid resuscitation)
Postural hypotension
Symptoms of dizziness
Decreasing urine output
Evidence of recurrent melaena / haematemesis /
PR bleeding (haematochezia)
Low risk patients

Consider for discharge or non-admission with
outpatient follow-up if:
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Age <60, and;
No evidence of haemodynamic disturbance (SBP >
100mmHg, pulse < 100bpm), and;
Not a current inpatient or transfer, and;
No witnessed haematemesis or haematochezia
(upper GI bleed) or
No evidence of gross rectal bleeding, and an obvious
anorectal source of bleeding on rectal examination +/rigid sigmoidoscopy (lower GI bleed)
Introduction to Upper GI Bleed
Pathway


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3 minutes, working individually
Fill in pathway for Case 1
Need:

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coloured case study sheet (any colour)
Upper GI bleed pathway
Use your imagination to fill in details not
stated!!!
Case 1
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PC/HPC 18F
Vomited x4 tonight, now streaks of red blood on 3rd
and 4th vomits
Has been out with friends tonight, had “a few drinks”
PMH – Fit and well
Drugs & Allergies – Nil
O/E Pulse 80 reg, BP 110/80 (no postural drop)
Abdomen soft, non-tender, no organomegaly
PR - empty rectum
Rest of examination normal
Case 1

Diagnosis


Severity


Mild
Rockall Score


Mallory Weiss tear
Age 0, Shock 0, co-morbidity 0 = 0
Ix and Mx

Senior r/v with view to discharge and OP OGD
Rockall Score (Upper GI only)
Score
Variable
0
1
2
Age
<60 years
60-79 years
>80 years
Shock
No shock
Tachycardia
Hypotension
Co-morbidity
No major
cormorbidity
Diagnosis
(Post OGD)
Mallory-Weiss
tear, no lesion
identified, no SRH
Major stigmata
of recent
haemorrhage
(Post OGD)
None or dark spot
only
CCF, IHD, major
comorbidity
All other
diagnoses
Pre OGD Score
0-1 next available list (Mortality <2.5%)
>=2 urgent OGD (Mortality 5%)
3
Renal failure, liver
failure,
malignancy
Malignancy of
upper GI tract
Blood in GI tract,
adherent clot,
visible or spurting
vessel
Post OGD Score
<3 good prognosis, early discharge
>8 high risk of death
Endoscopy – Upper GI Bleeds
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Severe bleeds

Urgent OGD, inform Surgeons and Critical Care
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If fails, may need emergency surgery
Moderate bleeds
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Suspected Varceal bleed
Continued bleeding, >4u blood to keep BP >100
Continuing fresh melaena / haematemesis
Re-bleed / unstable post resuscitation
IP OGD within 24hrs
Minor bleeds / unproven

Consider OP OGD
Mallory Weiss tear
Mallory Weiss tear

Hx

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Vomiting (++) prior to haematemesis
Often associated with alcohol
Small volume blood “streaks”, mixed with vomit
Ex

Normal examination
Benign Anorectal
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Haemorrhoids
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Feel “lump”, Itch
Anal Fissure

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Bright red blood on toilet paper, not mixed with
stools
Diagnosed by typical PR appearances
Anal pain +++ with motions
Fistula in aino

Soiling on underwear, recurrent abscesses
Anal Fissure
Haemorrhoids
Fistula in aino
Moderate & Sever Bleeds
Resuscitation
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Airway
Breathing
Circulation
Disability
Exposure
Airway & Breathing
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Large clots can block the airway
May have reduced conscious level
(shock/encephalopathy)
At risk of aspiration due to vomiting
Give 15l/min oxygen via face mask
Circulation – recognising
shocked patients
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Pale
Clammy skin
High Cap Refill (>2s)
Weak pulse
Tachycardia (NB beta blockers)
Hypotention
(High resp rate)
(Confusion)
Circulation - Interventions


2 large bore IV cannulae (14 or 16 G)
Send blood for FBC, clotting, G&S or X-match, if
bleeding is severe inform blood bank (see also
massive haemorrage protocol)

IV fluids to maintain BP>100 systolic


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Start with up to 2l N Saline Stat
Then progress to blood
IV FFP if variceal bleed suspected or INR>1.3
Urinary catheter
Blood
Blood

O Negative
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Type specific (red label ...)
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20 mins
transient response, ongoing bleed
Fully X matched
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immediately
shock not responding to IV fluids
40 mins plus
responded to fluids, but significant blood loss
Speak to lab technician they will know exact times!
Consider massive haemorrhage alert protocol
Massive Haemorrhage
Protocol

Purpose:


to improve and streamline blood administration to those
with massive blood loss
Massive Hemorrhage protocol kicks in in the
following circumstances:

Blood loss
 of 1 blood volume (5l) within 24hrs


of 50% blood volume (2.5l) within 3hrs


or
or
at rate of 150 mls/min
Medical Management

Stop
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Give
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Antihypertensives
NSAIDS
Anticoagulants
10mg IV vitamin K if INR >1.3
Consider
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2mg IV Terlipressin (stat then QDS)
Broad spectrum antibiotics (e.g. Tazocin 4.5g tds)
40mg IV Omeprazole bd
40mg oral Omeprazole od
Prescribing exercise


Jo Blogs (dob 01/01/1955, hospital no
X111000) is in Resus unstable with a
massive upper GI bleed (probably variceal)
Please prescribe him:

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2 units of blood
IV Tazocin
IV Terlipressin
Hand in your prescriptions at the coffee break
(with your name on) to be checked
Questions & Coffee Break
Why do we do investigations
in patients with GI bleeds?

Take a minute to brainstorm for reasons for
investigating patients with GI bleeds
Investigations - Reasons
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Confirm presence of bleeding
Allow safe blood transfusion
Plan treatment
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Assess degree of blood loss
Locate bleeding
Confirm suspected diagnosis
Assess extent (staging) of disease
Assess risk factors for bleeding
Investigations - Types
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Bedside
Blood tests
Imaging
Endoscopy
Surgery
Further details of all of these in Appendix at
end
Case Studies – Group Work


Groups of 4-5, same colour cases
For Case 2, list and justify:
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Diagnosis & 3 main differentials
Severity of Bleed
Rockall Score (pre endoscopy) if appropriate
Investigations & Management
Make flip chart
Present case afterwards
Clinical Guidelines available if desired
5-10 minutes
Red case 2
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PC/HPC 73M
Bright red blood with dark clots in last 4 bowel
motions (all today)
Mixed with stool (liquid) initially, now only blood
No abdominal pain
PMH – nil
Drugs – Movicol 1-2 satchets PRN
O/E BP 130/70 (no postural drop), P85, Hb 10.2
Abdomen soft, non tender
PR – Bright red blood plus darker clots+ in rectum
Case Red 2
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Diagnosis
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Severity
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moderate (neither mild nor severe)
Rockall Score

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Diverticular bleed
n/a – only for upper GI bleeds
Ix and Mx
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ABCDE resuscitation
Bloods (Hb level, exclude infection),?CT abdo, Flexi
sig once settled
Observe, ?antibiotics
Treatment – Lower GI Bleeds
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Haemostasis
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
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Most stop spontaneously +/- medical
management
Angiogram Embolisation
Occasionally surgery
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Generalised colonic bleeds (eg colitis)
Endoscopy rarely

Can’t see clearly
Treatment of underlying
disease
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Eg definitive treatment of

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Cancers
Ulcers
Diverticular disease
.....
Conservative, Medical or Surgical
Urgent or Elective
Diverticular Disease
Diverticular Disease

Hx
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Prone to constipation
Loose motion, then blood mixed in, then only
blood
Often out of the blue
Known diverticular disease
Ex
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Abdomen usually non tender
Blood PR, no masses, no anorectal pathology
Inflammatory Bowel Disease
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Hx
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Known IBD
Loose motions, up to 20x/day
Now mucus and blood, increased frequency
Ex
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Thin
Tender abdomen
Systemic signs of IBD
Ulcerative Colitis
Crohn’s Disease
Yellow 2
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PC/HPC 70 F
24hrs increasing generalised abdo pain (now severe++)
and diarrhoea
Now blood mixed with stools, bright and dark red
PMH AF, otherwise well
O/E Pulse 130 Ireg Ireg, BP 110/60 lying, 90/50 sitting,
RR 24, looks pale and clammy,
Abdomen soft, no localised tenderness
PR – blood mixed with mucus and liquid stool on finger
ABG – Lactate 5.1, pO2 12.4, pCO2 3.0, pH 7.35
Case Yellow 2
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Diagnosis


Severity
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Severe
Rockall Score


Ischemic colitis
n/a
Ix and Mx
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ABCDE resuscitation
ECG, Rigid sigi, Bloods (Hb, Trop I, U&Es,
inflammatory markers), CT abdo, Colonoscopy
NBM, IVI, Antibiotics, +/- Surgery
Ischemic Colitis

Hx
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AF / IHD
Generalised pain
Colitic symptoms
Very unwell
Ex
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“pain out of proportion with signs”
No localised signs (until perforation)
Acidosis
Case Blue 2
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PC/HPC 45 M attends A&E
3 episodes haematemesis today, bright red blood++
no other complaints from patient
PMH – admits nil
SH – 4 cans strong larger / day
Drugs – Thiamine, Vit B Co Strong
O/E HR 110bpm reg, BP 98/60
mildly confused (GCS 14/15)
Jaundiced, 3x spider nevi on chest and abdomen
Abdomen soft, non tender. RUQ tender mass, smooth, 1 finger
breath below costal margin, moves with respiration
PR – Dark red blood in rectum, no visible stools
Case Blue 2
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Diagnosis
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Severity
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Severe
Rockall Score
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Bleeding Varacies
Age 0, Shock 2, Co-morbidity 3 = Total 5
Ix and Mx


ABCDE resucitation, inc up to 2l fluids, FFP, ? blood
Terlipressin, Tazocin, ?Vitamin K, Urgent senior r/v,
urgent endoscopy
Rockall Score (Upper GI only)
Score
Pre endoscopy 5
Variable
0
1
2
Age
<60 years
60-79 years
>80 years
Shock
No shock
Tachycardia
Hypotension
Co-morbidity
No major
cormorbidity
Diagnosis
(Post OGD)
Mallory-Weiss
tear, no lesion
identified, no SRH
Major stigmata
of recent
haemorrhage
(Post OGD)
None or dark spot
only
CCF, IHD, major
comorbidity
All other
diagnoses
Pre OGD Score
0-1 next available list (Mortality <2.5%)
>=2 urgent OGD (Mortality 5%)
3
Renal failure, liver
failure,
malignancy
Malignancy of
upper GI tract
Blood in GI tract,
adherent clot,
visible or spurting
vessel
Post OGD Score
<3 good prognosis, early discharge
>8 high risk of death
Case Blue 2

OGD Results


Post endoscopy Rockall Score


Large oesophageal varices, no active bleeding.
Clots in stomach. Varices banded.
Diagnosis 1, SRH 2 Total 8
Outcome

High risk of death, needs close monitoring (e.g.
HDU / ITU)
Rockall Score (Upper GI only)
Score
Post endoscopy 8
Variable
0
1
2
Age
<60 years
60-79 years
>80 years
Shock
No shock
Tachycardia
Hypotension
Co-morbidity
No major
cormorbidity
Diagnosis
(Post OGD)
Mallory-Weiss
tear, no lesion
identified, no SRH
Major stigmata
of recent
haemorrhage
(Post OGD)
None or dark spot
only
CCF, IHD, major
comorbidity
All other
diagnoses
Pre OGD Score
0-1 next available list (Mortality <2.5%)
>=2 urgent OGD (Mortality 5%)
3
Renal failure, liver
failure,
malignancy
Malignancy of
upper GI tract
Blood in GI tract,
adherent clot,
visible or spurting
vessel
Post OGD Score
<3 good prognosis, early discharge
>8 high risk of death
Oesophagael Varices
Varices

Hx

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
Known liver disease
Known varices
High alcohol intake
Ex


Stigmata of liver disease
Smell of alcohol on breath
Yellow sclera
Caput Medusae
Man with gynaecomastia
Palmar erythema
Dupuytren’s contracture
Case Green 2
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PC/HPC
35M, GP admission to CDU
Diarrhoea today, and feeling a little faint at times, but hasn’t
passed out. Mild epigastric pain 1/7, settles with antacids.
PMH – Sports injury 10/7 ago, ?ACL damage
Drugs – nil regular, on pain relief for knee
Allergies - nil
O/E Pulse 100 reg, BP 110/60, (lying), 80/40 (standing)
Tender epigastrium, no guarding, stomach slightly bloated, no
organomegaly
PR – black, tarry motion, no red blood
Other examination normal
Case Green 2

Diagnosis


Severity


Severe
Rockall Score


Duodenal Ulcer
Age 0, Shock 2, Co-morbidity 0= Total 2
Ix and Mx


ABCDE, 2L fluids, +/- blood
IV Omeprazole, endoscopy within 24hrs, close
monitoring, ?Erect CXR (exclude perf)
Case Green 2

Results


OGD after 2hrs (pt deteriorated) – Blood in
stomach ++, large duodenal ulcer, spurting blood
Post endoscopy Rockall Score

Diagnosis 1, SRH 2, Total 5
Rockall Score (Upper GI only)
Score
Post endoscopy score 5
Variable
0
1
2
Age
<60 years
60-79 years
>80 years
Shock
No shock
Tachycardia
Hypotension
Co-morbidity
No major
cormorbidity
Diagnosis
(Post OGD)
Mallory-Weiss
tear, no lesion
identified, no SRH
Major stigmata
of recent
haemorrhage
(Post OGD)
None or dark spot
only
CCF, IHD, major
comorbidity
All other
diagnoses
Pre OGD Score
0-1 next available list (Mortality <2.5%)
>=2 urgent OGD (Mortality 5%)
3
Renal failure, liver
failure,
malignancy
Malignancy of
upper GI tract
Blood in GI tract,
adherent clot,
visible or spurting
vessel
Post OGD Score
<3 good prognosis, early discharge
>8 high risk of death
Gastric and Duodenal Ulcers
Gastritis
Peptic ulcers and Erosions

Hx





Associated with typical pain
NSAID use
Previous gastritis / ulcers
Stress (including operations)
Ex

Epigastric tenderness / guarding
Perforated ulcers


Ulcers rarely bleed and perforate
simultaneously
Suspect perforation if any abdominal
guarding



Localised epigastric guarding
Generalised peritonitis
If suspicious


get Erect CXR
Surgical input
Post op Complications


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
Rare ++++++
Must be considered if recent intervention
More commonly, re-bleeds post haemostaic
interventions
Can be very large bleeds, clots+++
Dieulafoy’s lesion




AV malformation
Very difficult to see at endoscopy
Frequently re-bleeds after intervention
Can be missed, so can bleed after “negative”
endoscopy
Case 3
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PC/HPC 48F, 1/12 increasing “heartburn”, associated
with weight loss (2/12), loss of appetite (2-3/52), and
being “off colour”. Bowels unchanged
Hb 6.0 MCV 74 (normal 80-100) at GP today, causing
admission (last Hb 1 ½ yrs ago 12.5)
PMH –normal OGD 2/52 ago, to Ix indigestion
?awaiting further tests
Normally fit and well
O/E – Pale, thin. Pulse 90, BP 140/85 (no postural
drop)
ECG
Case 3

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PC/HPC 48F, 1/12 increasing “heartburn”, associated with
weight loss (2/12), loss of appetite (2-3/52), and being “off
colour”. Bowels unchanged
Hb 6.0 MCV 74 (normal 80-100) at GP today, causing admission
(last Hb 1 ½ yrs ago 12.5)
PMH –normal OGD 2/52 ago, to Ix indigestion ?awaiting further
tests
Normally fit and well
O/E – Pale, thin. Pulse 90, BP 140/85 (no postural drop)
ECG immediately after arrival - ST depression
Abdomen - Vague Mass RIF, non tender
PR – soft brown stool on examining finger.
Case 3

Diagnosis


Severity


Angina caused by anaemia, secondary to cecal
carcinoma
Bleed is not acute but chronic, so n/a
Ix and Mx




Treat angina (GTN spray), consider ACS
Slow transfusion, +/- diuretic, as at risk of overload
(not acute blood loss, plus cardiac symptoms)
CT scan +/- colonoscopy to confirm diagnosis
Definitive treatment for cancer (Right Hemicolectomy)
Colon Cancer
Colorectal Malignancy

Hx




Weigh loss, loss of appetite, lethargy
Right sided – often only iron deficiency anaemia
Left side – change in bowel habit, blood mixed with
stool, mucus
Ex




Palpable mass (abdominal / PR)
Visible weight loss
Craggy liver edge
May be normal
Gastric Cancer
Oesophageal cancer
Features of Upper GI cancers



1 minute, work in pairs
Discuss features of history and examination
that suggest upper GI malignancy as cause
for bleed
List


3 features on history
3 findings on examination
Oesophageal & Gastric
Malignancies

Hx





Weight loss, loss of appetite, general lethargy
Dysphagia
Known malignancy
Recent stent insertion
Ex




Emaciated
Palpable craggy liver edge
Palpable neck LN (rare)
Visible mets (rare)
Summary (1)




Colour of blood important for location of bleed
Assess severity of bleed (including Rockall
Score) to decide urgency of management
Simultaneous Resuscitation, Investigations &
Management if unwell
Targeted investigations for less sick patients
Summary (2)




Likely diagnosis from history and examination
Working diagnosis to guide management
Use guidelines / pathways to aid
management
ASK FOR HELP when needed!!!
ANY QUESTIONS?
Appendix – Investigations for
GI bleed patients
Bedside

Fecal Ocult Blood (FOB)



Proctoscopy


Not commonly available now as bedside test
Still used in lab for bowel cancer screening
Anal canal
Rigid Sigmoidoscopy


Rectum and distal sigmoid colon
Up to 20cm max
Blood tests

FBC



LFTs & Clotting



Clotting disorders and risk factors for these
Liver failure, and risk of varacies
Tumour Markers



Hb level
? Chronic microcytic anaemia
CEA if suspected colon cancer
Ca19.9, Ca125 & CEA if suspected gastric cancer
G&S / Crossmatch

Allows transfusion
Imaging - location of bleed


All during active bleed
CT Angiogram


Angiogram



Non invasive, sensitivity & specificity 85-90%
Bleeds >0.5 ml/min
Therapeutic & diagnostic
Red Cell Scan - Tc-99m RBC scintigraphy

Slow volume bleeds, >0.1ml/min
CT Angiogram
Laing C J et al. Radiographics 2007;27:1055-1070
©2007 by Radiological Society of North America
Imaging – cause of bleed

CT abdomen & pelvis with contrast



Barium Enema


Diverticular disease, Colon Cancer
CT Colon


Acutely unwell, for cause including ?colitis
Staging suspected cancers
As for Ba Enema
Barium meal / follow-through

Investigate possible small bowel causes (Chron’s)
Transverse CT image
56-year-old man with
pseudomembranous
colitis who was
undergoing antibiotic
treatment for
endocarditis. In the
sigmoid colon, a
shaggy thickened bowel
wall with alternating
areas of necrosis
(arrows) and plaques is
visible
Endoscopy


Rigid scopes – see bedside tests
OGD (Oesophago-gastro-duodenoscopy,
Gastroscopy, Upper GI endoscopy)


For all Upper GI bleeds
Flexible Sigmoidoscopy

Suspected left sided colonic bleeds


Colonoscopy

Suspected right sided colonic bleeds


To splenic flexure, aprox 40-60cm
Whole colon visualised
Flexi Sig and Colon – not in bleeding patients

Poor vision – risk of perforation
Surgery




Last resort
When location not found, and ongoing
significant bleed
Can locate most proximal part of bowel with
blood in lumen, & Limited resection
If unclear, and colonic, occasionally total
colectomy